V.13.3 Special Report: Standardizing OB Data Definitions Report on the National ReVITALize Conference

I. Introduction

This V13.3 Special Report provides information related to efforts to standardize obstetric data definitions. Wide spread use of these operational definitions will improve the advancement and integration of performance measurement, registries, research, electronic health records, and birth certificates. Dissemination of the data definitions and the work of the Conference participants are critical to insuring the acceptance and use of the endorsed definitions. We are very pleased to participate in this process by using our quarterly special report platform to inform our members of the reVITALize work and have Dr. Kate Menard as a guest presenter during our quarterly webinar. NPIC/QAS will continue to update our membership on this important work as this effort progresses.

II. Standardizing Obstetrical Data Definitions: reVITALize

In August, 2012 the American Congress of Obstetrics and Gynecology (ACOG), with additional support from the March of Dimes, the Society for Maternal Fetal Medicine, and the United Health Foundation, brought together over 80 national leaders in women’s health care for the reVITALize Obstetric Definitions Conference.1 The Conference was chaired by Elliott K. Main, MD, FACOG and M. Kathryn Menard, MD, MPH, FACOG.

The goal of the conference was to standardize clinical obstetric data definitions for use in registries, electronic medical record systems, and vital statistics. Following pre-conference vetting, 69 individual data elements were presented for review. The definitions covered five areas relevant to care: gestational age and term; delivery; labor; maternal indicators - current co-morbidities and complications; and maternal indicators – historical diagnoses. Fifty- three revised data element definitions were developed and voted on by conference attendees - 9 did not receive sufficient support and required additional revision.

Following revision, 50 refined data element definitions were sent forward for public comment (through January 2013). Public comment review and finalization is now in process. (Appendix A lists the 49 data elements and their definitions that are “in press”.) Final confirmation of the definitions is expected by late spring/early summer.

III. Quarterly Data Submission Opportunities

As members of NPIC/QAS you have the unique opportunity to submit your perinatal data to a national comparative database that provides you with benchmarks on your volume, utilization, charges and quality metrics in comparison to similar hospitals (your subgroup) as well as all of the member hospitals in the database. This comparative data can help inform your internal and external quality initiatives regarding how to use your limited resources to improve care.

We are invested in improving the quality and validity of the submitted data as well as expanding the data set by adding data elements from multiple sources within your institution. Our current data request includes many items that “live” in an electronic format within your institution but may not be submitted on your hospital’s quarterly file. Below is a listing of some of the key perinatal data elements that we request and the percent of hospitals submitting that element. We encourage you to review the data submitted by your facility and we are happy to work with you to submit additional elements. We are acutely aware that IT staff are extremely busy so adding data fields to the current file is not always practical. In most cases, additional or supplemental data elements can be put on an excel spreadsheet with a couple of linking variable (MRN, DDate, etc.) and uploaded securely to our data portal.

Table 1: Perinatal Data Elements Requested by NPIC/QAS % of Total # Hospitals Submitting Discharges Data Element (% of total - (Inborns or Note n=78) Deliveries) Numeric GA 64 94.4% Allows for discrimination (82.1% of total between early term, term, late hospitals) term and post term infants Numeric BW 78 (100%) 98.5% Refined analyses by BW Mother/Baby 75 (96.2%) 97.3% Linked analyses link (MMRN provided) Gravida 31 (39.7%) 84.6% Parity 44 (56.4%) 74.2% Able to identify nulliparous deliveries Date of delivery 43 (55.1%) 77.0% Able to identify long antepartum stays Present on 42 (53.8%) 64.9% Joint Commission exclusions for Admission PC 04 (POA) APGAR@ 1 min 69 (88.5%) 95.3% APGAR@ 5 min 72 (92.3%) 95.1% Adverse Outcome Index variable Intensive care 24 (30.8%) - Prior to delivery or immediately admit date following Associated dx 45 - Improved case mix profiling 18-24 (57.7%) Associated opp 13 - codes 7-24 (16.7%)

Table 2: The Joint Commission Perinatal Care Measure Data Elements generally requiring abstraction/confirmation

Data Element Note PC 01-05a Prior Uterine Surgery PC 01 Labor PC 01 Spontaneous Rupture of Membranes PC 01 Antenatal Steroid therapy initiated PC 03 Reason for not administering PC 03 antenatal steroid therapy Exclusive Breast Milk Feeding PC 05-05a Reason for not Exclusively Feeding PC 05-05a Breast Milk

Please connect with your hospital liaison to discuss submission of additional data elements.

REFERENCES

1 http://www.acog.org/reVitalize

Appendix A: reVITALize Elements and Definitions (Please note: these data definitions are “in press” as of 3/28/2014) Element name Definition Notes CESAREAN BIRTH Birth of the (es) from the uterus Does not apply if any of the following through an abdominal incision occur: Abdominal pregnancy Ectopic Pregnancy

Add separate data item to indicate presence of labor or no labor PRIMARY Birth of the fetus(es) from the uterus Does not apply if any of the following CESAREAN BIRTH through an abdominal incision in a occur: woman without a prior cesarean birth Abdominal pregnancy Ectopic Pregnancy

REPEAT CESAREAN Birth of the fetus(es) from the uterus Does not apply if any of the following BIRTH through an abdominal incision in a occur: woman who had a cesarean birth in a Abdominal pregnancy previous pregnancy Ectopic Pregnancy

FORCEPS Application of forceps to the fetal Should specify whether successful or ASSISTANCE head unsuccessful in achieving birth This includes both cesarean and vaginal births VACUUM Application of vacuum to the fetal Should specify whether successful or ASSISTANCE head unsuccessful in achieving birth This includes both cesarean and vaginal births VERTEX A fetal presentation where the head Should specify whether position is PRESENTATION is presenting first in the pelvic inlet anterior, posterior, or transverse.

Does not apply if compound or breech presentation or if brow, face, hand, shoulder, etc. present first in the pelvic inlet MALPRESENTATION Any presentation other than a vertex presentation

Examples: Brow, face, compound, breech, hand, shoulder, etc. PERINEAL 1°: Injury to perineal skin only LACERATIONS 2°: Injury to perineum involving perineal muscles but not involving anal sphincter 3°: Injury to perineum involving anal sphincter complex 3a: Less than 50% of External Anal Sphincter (EAS) thickness torn 3b: More than 50% External Anal Sphincter (EAS) thickness torn 3c: Both External Anal Sphincter (EAS) & Internal Anal Sphincter (IAS) torn 4°: Injury to perineum involving anal sphincter complex (External Anal Sphincter (EAS) & Internal Anal Sphincter (IAS)) and anal epithelium PLACENTA The clinical condition in which any Accreta may or may not be supported ACCRETA part of the placenta invades and is by pathologic findings inseparable from the uterine wall SHOULDER A birth complication that requires DYSTOCIA additional maneuvers to relieve impaction of the fetal shoulder SPONTANEOUS Birth of the fetus through the vagina VAGINAL BIRTH without the application of vacuum or forceps or any other instrument

Does not apply if the following occurs: Breech extraction SPONTANEOUS Birth of the fetus in a breech VAGINAL BREECH presentation through the vagina BIRTH without the application of vacuum or forceps or other instrument VAGINAL BIRTH A vaginal birth in a woman with one AFTER CESAREAN or more previous cesarean births (VBAC) GESTATIONAL AGE & TERM GESTATIONAL AGE Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical EDD based on the following formula: Gestational Age = (280 - (EDD - Reference Date))/ 7

EDD: Estimated Due Date

REFERENCE DATE Date on which you are trying to determine gestational age ESTIMATED DUE The best Estimated Due Date is Ultrasound margin of error and DATE determined by: “early” to be defined by ACOG Last menstrual period (LMP) if Pregnancy should not be re-dated by a confirmed by early ultrasound or later ultrasound after a best obstetrical no ultrasound performed, or estimate of EDD has been established

Early ultrasound if no known LMP or the ultrasound is not consistent with LMP, or

Known date of fertilization (eg. ART, IUI)

PRETERM Less than 37 weeks and 0 days Late Preterm is 34 weeks and 0 days through 36 weeks and 6 days TERM Greater than or equal to 37 weeks and 0 days using best EDD. It is divided into the following categories: Early Term - 37 weeks and 0 days through 38 weeks and 6 days

Full Term - 39 weeks and 0 days through 40 weeks and 6 days

Late Term - 41 weeks and 0 days through 41 weeks and 6 days

Post Term - Greater than or equal to 42 weeks and 0 days LABOR Uterine contractions resulting in Avoid the term ‘prodromal labor’ cervical change (dilation and/or Can be spontaneous in onset, effacement) spontaneous in onset and subsequently augmented, or induced Phases:

Latent phase – from the onset of

labor to the onset of the active

phase

Active phase – accelerated

cervical dilation typically beginning at 5 cm for multiparous women and at 6 cm for nulliparous women THE TIME OF THE The time when regular uterine ONSET OF LABOR contractions began that resulted in labor with or without the use of pharmacological and/or mechanical interventions AUGMENTATION OF The stimulation of uterine LABOR contractions using pharmacologic methods or artificial rupture of membranes (AROM) to increase their frequency and/or strength following the onset of spontaneous labor or contractions following spontaneous rupture of membranes

Does not apply if the following is performed: Induction of Labor

INDUCTION OF The use of pharmacological and/or LABOR mechanical methods to initiate labor

Examples of methods include but are not limited to: artificial rupture of membranes, balloons, oxytocin, prostaglandin, laminaria, or other cervical ripening agents

Still applies even if any of the following are performed: Unsuccessful attempts at initiating labor

Initiation of labor following spontaneous ruptured membranes without contractions NUMBER OF The last documented cervical Cervical dilation may be unknown CENTIMETERS dilation, in centimeters, when the with: DILATED ON provider orders admission Preterm labor ADMISSION Rupture of membranes Vaginal bleeding Exam refusal by patient (decline)

Cervical assessment may be performed by any clinician DURATION OF Duration from rupture of membranes RUPTURED to birth (in hours and minutes) MEMBRANES ARTIFICIAL An intervention that perforates the RUPTURE OF amniotic sac MEMBRANES Applies even if the rupture of (AROM) membranes occurs during or immediately following a procedure or exam not intended to cause AROM

Does not apply if rupture of membranes occurs during cesarean birth SPONTANEOUS A rupture of the amniotic sac that is May occur at any gestational age RUPTURE OF not concurrent with or immediately MEMBRANES (SROM) following a digital exam or other transvaginal intervention involving the amniotic membrane

Does not apply if the following is performed: Artificial rupture of membranes PRE-LABOR Spontaneous rupture of membranes Modified by gestational age categories RUPTURE OF that occurs before the onset of labor (e.g. Preterm, term) MEMBRANES LABOR AFTER Labor in a woman who has had one Should qualify the intended route of CESAREAN (LAC) or more previous cesarean births birth on admission

Planned LAC occurs in a woman May result in a vaginal or cesarean intending to achieve a vaginal birth. birth

Unplanned LAC occurs in a woman intending a repeat cesarean birth. PHYSIOLOGIC Spontaneous labor and birth at term without the use of pharmacologic and/or mechanical interventions for labor stimulation or pain management throughout labor and birth

Does not apply if any of the following are used or performed: Opiates/nitrous oxide Augmentation of labor Regional anesthesia analgesia except for the purpose of spontaneous laceration repair Artificial rupture of membranes

Still applies if any of the following are used: Uterotonic in the 3rd stage of labor

Medications that do not stimulate labor or provide pain management (e.g. Antibiotics, medications to control chronic medical conditions) SPONTANEOUS Initiation of labor without the use of LABOR AND BIRTH pharmacological and/or mechanical interventions, resulting in a non- operative vaginal birth

Does not apply if any of the following are used or performed: Cervical ripening agents, mechanical dilators, or induction of labor

Forceps or vacuum assistance Cesarean birth

Still applies if any of the following are used or performed: Augmentation of labor

Episiotomy

Regional anesthesia SPONTANEOUS Labor without the use of May occur at any gestational age ONSET OF LABOR pharmacological and/or mechanical interventions to initiate labor

Does not apply if the following is performed: Artificial rupture of membranes before the onset of labor ABRUPTION Placental separation from the uterus with bleeding (concealed or vaginal) before fetal birth, with or without maternal/fetal compromise

Does not apply if the following occurs: Placenta previa ANTENATAL At least one dose of STEROIDS was administered to accelerate fetal INITIATED maturation CLINICAL Usually includes otherwise Non-laboring, intact membranes with unexplained fever (at or above 38 unexplained fever requires additional degree C (100.4F)) with one or more testing of the following: Clinical diagnosis could be supported Uterine tenderness and/or by laboratory evaluation of amniotic irritability fluid Leukocytosis Fetal tachycardia

Maternal tachycardia Malodorous vaginal discharge

POSTPARTUM HEMORRHAGE EARLY Cumulative blood loss of >=1000ml Signs/symptoms of hypovolemia may POSTPARTUM OR blood loss accompanied by include tachycardia, hypotension, HEMORRHAGE sign/symptoms of hypovolemia tachypnea, oliguria, pallor, dizziness, within 24 hours following the birth or altered mental status process (includes intrapartum loss). Cumulative blood loss of 500-999ml alone should trigger increased supervision and potential interventions as clinically indicated

A fall in hematocrit of >10% can be supportive data but generally does not make the diagnosis of postpartum hemorrhage alone

Further research is needed on blood loss for late postpartum hemorrhage PARITY The number of reaching In cases of multiple pregnancies, 20 weeks and 0 days of gestation or parity is only increased with birth of beyond, regardless of the number of the last fetus or outcomes NULLIPAROUS A woman with a parity of zero PLURALITY The number of fetuses birthed live or dead at any time in a single pregnancy regardless of gestational age, and regardless of if the fetuses were birthed on different dates

Does not apply if any of the following occur: “Reabsorbed” fetus(es) (those that are not birthed separately from the placenta and membranes)

A reduction during the first trimester GRAVIDA A woman who currently is pregnant or has been in the past, irrespective of the pregnancy outcome GRAVIDITY The number of pregnancies, current and past, regardless of the pregnancy outcome PRE-GESTATIONAL Diabetes diagnosed before current DIABETES pregnancy (coordinate with GDM). CHRONIC HYPERTENSION

CHRONIC See National Center for Health HYPERTENSION Statistics (NCHS) definition: (EXISTING PRIOR TO Elevation of blood pressure above PREGNANCY) normal for age, gender, and physiological condition. Diagnosis prior to the onset of this pregnancy- does not include gestational hypertension (pregnancy induced hypertension (PIH)). CHRONIC Hypertension diagnosed before the HYPERTENSION 20th week of current pregnancy. DIAGNOSED DURING CURRENT PREGNANCY MATERNAL WEIGHT The last recorded maternal weight Weights used for the calculation GAIN DURING prior to birth minus the last recorded should be from the best available PREGNANCY weight immediately prior to information pregnancy NON-CESAREAN Surgery/injury and healing of the UTERINE myometrium prior to birth other than SURGERY/SURGICAL from cesarean birth SCAR POSITIVE GBS RISK Rectal/vaginal culture positive STATUS within 5 weeks prior to birth, or

Urine GBS culture positive* or GBS bacteruria at any point in current pregnancy, or

Prior infant with invasive GBS disease